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Vol. 43 

Friday, 3 January 1964 

No. 1 


IMPORTANT - News Letter Renewal Notice Required 3 


Chemotherapy and Radiotherapy 
in Nonresectable Lung Cancer. . 5 

Tropical Medicine Symposium: 

Recent Concepts of Amebiasis. . 8 
Clinical Aspects of Asiatic 

Cholera 11 

Leishmaniasis - Epidemiology 13 


Disease and Injury Codes 

BuMed Notice 6310 15 

Immunization for International , 

Travelers in 1964 16 

International Certificates of 

Vaccination 16 

Drug Literature Report 16 

Trachoma Virus - a Bacterium . .17 

Missile Emergency Teams 17 

Indianapolis Hospitals in Recent 

Blast Emergency 18 


International Naval Medical 

Conference 19 

Reunion of NAMRU-2 Members. . .19 
New Research Billet 20 

Tests of Antimalarial Drug 20 

Medical Research Reports 21 


Prevention of Cerebrovascular 
Accidents . . . . 

Evaluation of Fluoride Therapy. 

Oral Neomycin and Absorption 
of Penicillin V 

Personnel and Professional 





Acute Chlorobromomethane 

Toxicity 27 

Explosion Hazard of Combustible 

Gases, Vapors, and Dusts .... 31 

Accidentally Ingested Products . - 34 

DHEW PHS Announcement 37 


Promotion Zones and Convening 
Dates 38 

Navy Ensign 1915 Medical 

Program (Continued) 39 

United States Navy 

Vol. 43 Friday, 3 January 1964 No. 1 

Rear Admiral Edward C. Kenney MC USN 

Surgeon General 

Rear Admiral A.S. Chrisman MC USN 

Deputy Surgeon General 

Captain M. W. Arnold MC USN (Ret), Editor 

Contributing Editors 

Aviation Medicine Captain C. E. Wilbur MC USN 

Dental Section Captain C. A. Ostrom DC USN 

Occupational Medicine ........ CDR N. E. Rosenwinkel MC USN 

Preventive Medicine Captain J. W. Millar MC USN 

Radiation Medicine CDR J. H. Schulte MC USN 

Reserve Section Captain K. W. Schenck MC USNR 

Submarine Medicine CDR J. H. Schulte MC USN 


The U.S. Navy Medical News Letter is basically an official Medical Depart- 
ment publication inviting the attention of officers of the Medical Department 
of the Regular Navy and Naval Reserve to timely up-to-date items of official 
and professional interest relative to medicine, dentistry, and allied sciences. 
The amount of information used is only that necessary to inform adequately 
officers of the Medical Department of the existence and source of such infor- 
mation. The items used are neither intended to be, nor are they, susceptible 
to use by any officer as a substitute for any item or article in its original 
form. All readers of the News Letter are urged to obtain the original of those 
items of particular interest to the individual. 

Change of Address 

Please forward changes of address for the News Letter to: Commanding Officer, 
U.S. Naval Medical School, National Naval Medical Center, Bethesda, Maryland, 
giving full name, rank, corps, and old and new addresses. 

The issuance of this publication approved by the Secretary of the Navy on 
28 June 1961. 

Medical News Letter, Vol. 43, No, 1 3 

I-M-F-O-R-T-A-N-T N-O-T-I-C-E 

U.S. Navy Medical News Letter Renewal Request Is Required 

Existing regulations require that all Bureau and office mailing lists be checked 
and circularized once each year in order to eliminate erroneous and duplicate 

It is, therefore, requested that EACH RECIPIENT of the U. S. Navy 
Medical News Letter {Except U. S. Navy and Naval Reserve personnel on 
ACTIVE DUTY and U. S. Navy Ships and Stations) fill in and forward imme- 
diately the form appearing below if continuation on the distribution list is 
desired. However, all recipients, Regular and Reserve , are responsible for 
forwarding changes of address as they occur. 

Failure to reply to the address given below by 15 February 1964 will 
automatically cause your name to be removed from the files. If you are in an 
Armed Service other than Navy, please state whether Regular, Reserve, or 

Also, PLEASE PRINT LEGIBLY. If names and addresses cannot be 
deciphered, it is impossible to maintain correct listings. 

— Editor 

(Detach here) 

Commanding Officer, U. S. Naval Medical School 

National Naval Medical Center (date) 

Bethesda, Md. , 20014 
(Attn: Addressograph Office) 

I wish to continue to receive the U. S. Navy Medical News Letter. 


Activity Ret 

or (Print or type, last name first) (rank, service, corps) 

Civilian Status 


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Medical News Letter, Vol. 43, No. 1 


Melvin J. Krant MD, Thomas C. Chalmers MD, Margarida M. Dederick 
MD, Thomas C. Hall MD, Martin B. Levene MD, Hugo Muench MD and 
Dr P.H. , Bruce I. Shnider MD, G. LennardGold MD, Charles Hunter MD, 
Solomon R. Bersack MD, Albert H. Owens Jr, MD, Natividad de Leon MD, 
Robert J. Dickson MD, Clyde Brindley MD, Kirkland C. Brace MD, Emil 
Frei III MD, Edmund Gehan PhD, and Leonard Salvin MS. Amer J Med 
35(3): 363-373, September 1963. 

Cancer of the lung continues to be a major health problem for which little 
successful therapy has been devised to date. The over-all curative results 
with surgery continue to be poor, the 5 -year survival rate being 5% to 12%. 
As a member of the Eastern Cooperative Group in Solid Tumor Chemotherapy, 
the Lemuel Shattuck Hospital conducted a preliminary trial in 1958 in which 
supervoltage radiotherapy was compared to mechlorethamine (nitrogen mus- 
tard) therapy in patients with inoperable carcinoma of the lung. This study 
indicated that radiotherapy was superior to mechlorethamine therapy alone in 
causing transient shrinking of the pulmonary tumor, although survival was un- 
affected. Thereupon, the group undertook a cooperative study to compare the 
therapeutic efficacy of three treatment schedules. 

There were three "treatment groups": Group I consisted of patients 
given radiation therapy alone, in a dosage of 4000 r to tumor tissue. Group II 
included patients given radiotherapy and mechlorethamine treatment simul- 
taneously. Group III was comprised of patients given mechlorethamine fol- 
lowed by radiotherapy. The study attempted to answer three questions: 
(1) Was early radiotherapy repeatedly superior to early mechlorethamine 
therapy in causing shrinkage of the lung cancer? (2) Did the simultaneous or 
prior administration of mechlorethamine with radiotherapy augment the shrink- 
age of the tumor mass? (3) Did mechlorethamine therapy affect distant overt 
and occult metastases and thus extend survival time? 

This report is the analysis of findings in 219 patients so treated from 
October 1958 to February 1961. Of this group, 196 (89%) had received no 
prior therapy except for explorative surgery. A preliminary report of the 
results has been published (1). 

Method of Study 

Four member institutions cooperated in placing patients in the study: The 
District of Columbia General Hospital (Georgetown University Service) and 
Mt. Alto Veterans Administration Hospital; Johns Hopkins Hospital; National 
Cancer Institute; and Lemuel Shattuck Hospital. All patients admitted to these 
hospitals were considered for the study when the following criteria were met: 
(1) biopsy proof of inoperable or recurrent bronchogenic carcinoma of any 

6 Medical News Letter, Vol. 43, No. 1 

histologic type; (2) existence of a pulmonary lesion visible on roentgenograms 
but not necessarily clearly measurable; (3) any previous treatments with either 
radiotherapy or alkylating agents (one course only) concluded at least 6 weeks 
before the start of the study and not administered as part of the study by mem- 
bers of this group; (4) not under active treatment with antibiotics at the time 
of entry into the study; and (5) acceptable to the radiotherapist for immediate 
or delayed therapy. The names of all patients seen by the investigators as 
potential candidates for the study were entered in a logbook maintained in 
each institution. Reasons for exclusion of a patient from the study were noted. 

Following acceptance for the study, the patients were divided into three 
groups: (1) those who had prior radiotherapy; (2) those who had prior chemo- 
therapy; and (3) those who had no previous antitumor therapy. For each hos- 
pital selection of patients for treatment then was effected by the envelope 
method, and the patients were placed in the appropriate treatment group. 
(Selection slips had been arranged predeterminedly by the Biometrics staff 
at the Cancer Chemotherapy National Service Center.) The envelope could not 
be opened unless the patient could start therapy promptly. If for any reason 
the form of therapy assigned subsequently was discontinued, the patient still 
was considered part of the trial and included in the final tabulation of results. 

For purposes of the study, all patients were followed through the 
course of treatment and subsequently for a total of 90 days after initiation of 
therapy; thereupon, data continued to be collected but at less frequent intervals 
with all patients followed up until death, when possible. 

A record of such data as weekly weights, performance, symptoms, 
signs, and laboratory findings was kept and maintained for each patient. In 
addition, a grid map of the patient's measurable lesions and a flow sheet of 
sequential measurements were kept as part of the patient's record. These 
records were mimeographed and submitted to all senior investigators involved 
in the study for analysis at the time of voting (vide infra). Further details of 
the mechanics of study may be found in the paper of Zubrod et al (2). 

In the original article, the authors present sections on details of treat- 
ment, response to treatment, results, intergroup analysis, and comments. 


Two hundred and nineteen patients with carcinoma of the lung were studied 
in three treatment groups in a cooperative in-hospital study. Of these same 
patients, 196 had not received prior therapy. 

Treatment Group I was given a mean of 3842 tissue r; treatment Group 
II, a mean of 37.8 mg of nitrogen mustard therapy and 3658 tissue r simultan- 
eously; treatment Group III was given 41. mg nitrogen mustard therapy fol- 
lowed by 3633 tissue r. 

In evaluating shrinkage in tumor size benefits as determined by votes 
of the investigators and by over-all survival curves, essentially no beneficial 
differences emerged for any one treatment group. Toxicity was slightly 
greater in Group II, and treatment time extended for these same patients. 

Medical News Letter, Vol. 43, No. 1 7 

No difference in toxicity or survival time appeared between Z50 kv or 2 Kiev 
radiotherapy equipment. 

Data and discussion are presented to indicate that, in this study, 
survival time is independent of the form of treatment administered, but that 
natural selection alone determines the patients with longer survivorship. 
The routine use of radiotherapy and mechlorethamine treatment, therefore, 
is questioned. 

* Reported as a study by the Eastern Cooperative Group in Solid Tumor 
Chemotherapy (see Acknowledgement for participating members) from 
the Medical, Radiological, and Biostatistical Departments, Lemuel 
Shattuck Hospital, Department of Public Health, Commonwealth of 
Massachusetts, Boston, Mass; Medical and Radiological Departments, 
District of Columbia General Hospital, and Mt Alto Veterans Adminis- 
tration Hospital, Washington, D. C. ; Medical and Radiological Depart- 
ments, Johns Hopkins Hospital, Baltimore, Md. ; and the Medical, Radio- 
logical, and Biostatistical Departments, National Cancer Institute, Beth- 
esda, Md. This study was supported by Grants CYP-2820, CYP-2824, 
and CA-02823-07 from the National Cancer Institute. 

Acknowledgement : The Eastern Cooperative Group in. Solid Tumor Chemo- 
therapy includes the following members : Drs Dr Krant, Chalmers, Dederick, 
Hall, Levene, and Muench from the Lemuel Shattuck Hospital; Drs Shnider, 
Gold, Hunter, and Bersack from Mt Alto Veterans Administration Hospital; 
Drs Owens, de Leon, and Dickson from Johns Hopkins Hospital; and Drs 
Brindley, Brace, Frei, Gehan, and Salvin from the National Cancer Institute. 
Special thanks are extended to Miss Susan Gordon of the Biostatistical Section 
at the Lemuel Shattuck Hospital for her valuable help. 


1. Chalmers, T. C. Combination of radiotherapy and chemotherapy in 
the treatment of carcinoma of the lung. (Report of the Eastern 
Cooperative Group in Solid Tumor Chemotherapy) Cancer Chemo 
Reports, No. 16, February 1962. 

2. Zubrod, C. G. , Schneiderman, M. , Frei, E. , III, Brindley, C. , 
Gold, G. L. , Shnider, B. , Oviedo, R. , Gorman, J., Jones, R. Jr. , 
Jonsson, U. , Colsky, J. , Chalmers, T. , Ferguson, B. , Dederick, 
M. , Holland, J. , Selawry, O. , Regelson, W. , Lasagna, L. , and 
Owens, A. H. Jr. Appraisal of methods for the study of chemotherapy 
of cancer in man; comparative therapeutic trial of nitrogen mustard 
and triethylene thiophosphoramide. J Chron Dis 11:7, I960. 

ft 30C 3JC 30C 3fe 5& 

Medical News Letter, Vol. 43, No. 1 

Recent Advances and Concepts About Amebiasis 

Quentin M. Geiman PhD, Professor of Preventive Medicine, Stanford 
University School of Medicine. 

The topic chosen for this presentation expresses its purpose — to bring grad- 
uate physicians up to date on diseases or procedures that have either been 
omitted or inadequately taught in most medical schools; to acquaint them with 
problems of diagnosis, treatment, and control of amebiasis and other enteric 
disorders. With the development of chemotherapy, antimalarial compounds, 
antibiotics, modern insecticides such as DDT, it has been possible not only to 
control but to eradicate many diseases in tropical areas. 

Meager advances have been made, however, in the case of enteric dis- 
eases, amebiasis, and malnutrition. Even tuberculosis presents a different 
problem in the tropics — where a confirmed case may share a dirt-floored, 
thatched hut with six to sixteen other people — than in a self-sufficient educated 
family in the San Francisco Bay Area. Measles and whooping cough may have 
a serious acute course in undernourished children of the tropics. However 
much the Armed Forces may plan to be self-sufficient in the tropics, they 
will encounter native populations with different customs, lack of sanitation, 
rigors of heat and humidity, contaminated water, insect vectors of disease, 
animal hosts with a potential for transmitting disease, and loci of endemic 
disease. Familiarization with these hazards is essential for the preservation 
of the health of personnel. 

In dealing with amebiasis, it is easy to forget that one is not concerned 
with amebic infection alone, nor even with bacillary dysentery; here is a pa- 
tient with diarrhea, frequent stools containing blood, dysentery. Gastro- 
enteritis, another synonym, can occur anywhere in the intestinal tract. Many 
infections and toxins can produce this picture, as can food sensitivity, pella- 
gra, sprue, other organic bowel disease, and emotional disorders. Enteric 
diseases are a major cause of death in many countries; they are, in fact, the 
major cause in eight South and Central American countries. 

By present methods of bacteriologic and parasitologic attack on the 
diagnosis of gastroenteritis, the pathogen may be found in only 40% to 70% of 
cases. Concerted study in Puerto Rico by a bacteriologist, a parasitologist, 
and a virologist showed shigellosis to be responsible for a certain percentage 
of infections, intestinal parasites for a small percentage, and enteropathogenic 
coli or viruses for important percentages. A team, then, is often required. 
Results of teamwork are well exemplified by experience in a Korean POW 
camp. Within a few months, the number of infected cases rose from 27 to 

This is the eighth paper from the Tropical Medicine Symposium, USNH 
Oakland, Calif. , March 14 and 15, 1963. The preceding papers were 
published in the Medical News Letters of 15 November and 6 December 
1963. Edited by Captain Arthur J. Draper MC USN, and authorized by 
the CO of the Hospital, Rear Admiral Cecil L. Andrews MC USN. 

Medical News Letter, Vol. 43, No. 1 9 

23 72; the deaths from 7 to 176. It was evident that an epidemic had developed; 
officers in charge called for help. A team of clinicians, bacteriologists, para- 
sitologists, preventive medicine officers, and sanitary engineers was dis- 
patched to the scene. Within months, the epidemic was brought under control. 
Charted were the clinical signs and symptoms that went with amebic and 
bacillary dysenteries, stools per day, character of the stools, type of exudate, 
incidence and severity of abdominal pain, tenesmus, nausea and vomiting, 
maximum temperatures, and results of sigmoidoscopic examinations. By con- 
trast, was the instance of a ship which listed 75 cases of infectious hepatitis 
before a call for help was issued. Knowing when to call for help is a most 
important duty for the medical officer ! 

Amebiasis is one of the common enteric diseases; it is of worldwide — 
not merely tropical— distribution. An insidious infection, it is sometimes 
difficult to diagnose and to treat. The cystic stages are responsible for the 
transmission of the disease in fecal -contaminated food and drink. The dosage 
of fecal contamination determines the numbers of cysts that invade the tissues 
of the small and large bowel; from each cyst, eight amebiolae invade the 
intestine. These are the stages grown in culture. Stained specimens from 
stool preparations show red blood cells because the lesions occur in the bowel 
wall. Early cysts containing one nucleus develop into the mature form con- 
taining four. "Small-race" histolytica constitute a current academic problem; 
they are like a dwarf or miniature histolytica . Nonpathogenic, they readily 
respond to treatment. The question of their diagnostic importance and ter- 
minology has still not been answered. 

Amebic ulcers in the bowel show a characteristic bottle shape; the 
amebae themselves are to be found in the outer margin of the lesion. An 
attempt should be made by the sigmoidoscopist to express material for study 
from any ulcer he may encounter because organisms other than amebae may 
also be demonstrated in this manner. Early lesions begin in the bottom of a 
gland of the large bowel, cluster, penetrate, and cause necrosis. From the 
submucosa, the organisms gain entrance to the portal circulation and, hence, 
to the liver. From thence, they may extend through the diaphragm into the 
lungs. Identification of the organism lying within tissue is easy. The bowel 
lesion may be confused, however, with the much rarer balantidial lesion. 
Amebic ulcers commonly occur in the cecum; 87% of patients show lesions in 
this region. The proctoscopist should remember this distribution! 

Superimposed bacterial infection is suggested by widespread inflam- 
matory reaction as seen at sigmoidoscopy. In bacillary dysentery, the char- 
acteristic lesions are much more superficial than in amebiasis, and are 
surrounded by much more hyperemia and superficial inflammation. Sigmoid- 
oscopy is not only useful in discovery of the initial lesions of amebiasis, but 
is a valuable tool in assessment of response to treatment. After treatment 
has begun, the procedure should be repeated three times at weekly intervals; 
the progress of healing can be directly observed. 

The chief complications of amebic infection include ameboma, or 
chronic granuloma of the large bowel, liver abscess, and lung abscess 

10 Medical News Letter, Vol. 43, No. 1 

forming by extension from hepatic involvement. Ameboma is extremely hard 
to diagnose; it may mimic carcinoma or may occur in conjunction with carci- 
noma. Hence, surgical intervention is commonly necessary. The signs of 
liver abscess, fever, hepatic enlargement and tenderness, and the use of 
aspiration for diagnosis are not discussed in detail. 

In the diagnosis of amebiasis, the skilled laboratory technician is the 
physician's best friend. A series of fresh stool specimens should be examined 
unstained, stained, and by the concentration technic. Direct examinations of 
fresh specimens lead to discovery of the organisms in 2 7% of infected patients; 
stained films, to their demonstration in 39%; and concentration technics, to 
59%. Employment of all three technics gives the maximum yield. The con- 
centration technic is good only for finding cysts. Many examinations may be 
required. In one case studied at Boston City Hospital, the organism was not 
found until the eighteenth stool had been examined. The organisms, be it 
noted, are not excreted at a constant rate. 

Control of amebic infection involves environmental sanitation, proper 
personal hygiene, and treatment of cases, both those with acute infection and 
carriers. Carriers should certainly be treated in areas whexe there is poor 
environmental sanitation. Proper disposal of feces is very important, but 
may constitute quite a problem. Disposal in a desert area is one thing; in 
areas like Southeast Asia where the water table is at ground level, it is quite 
another. This is a job for the sanitary engineer. Fly control to prevent con- 
tamination of food and water is important but, of course, difficult, particularly 
in desert areas. Cysts of the organism need frequent superchlorination of 
water for riddance up to 12 to 18 parts per million. Globaline tablets devel- 
oped by the U. S. Army in World War II were quite effective. Composed of 
an organic iron compound — not chlorine — they are effective not only against 
amebae but against bacteria as well. Off duty, military personnel must 
exercise rigid eating precautions and practice meticulous personal hygiene. 

For treatment, there is as yet no drug available which will give 100% 
radical cure of amebic infection. As many as eighty different regimens have 
been tried in South Africa. Formerly, a course of emetine, followed by car- 
barsone, then by a broad-spectrum antibiotic was recommended. Emetine 
and chloroquine are, of course, highly effective for liver complications, but 
they do not produce a high percentage of cures of the intestinal form of infec- 
tion. Some older compounds, however, are as effective as any currently 
available. Some act directly upon the parasites; others, upon the associated 
bacteria. The combination of carbarsone and a broad spectrum antibiotic is 
the regime most commonly employed at present. Enterovioform is receiving 
extensive trials. Effective control of shigellosis with this agent was first 
reported. Similar results were attained against amebiasis. An extremely 
high relapse rate, however, was noted in the case of both diseases. The drug 
is prophylactic, not curative. Further studies of populations in tropical areas 
are definitely in order. 

* # sje $ * # 

Medical News Letter, Vol. 43, No. 1 11 

Clinical Aspects of Asiatic Cholera 

CDR Raymond H. Watten MC USN, Director, Clinical Investigation 
Center, U.S. Naval Hospital, Oakland, Calif. 

Dreaded throughout the East, cholera has been estimated to have caused one 
million deaths during the past 10 years, not only in India and Pakistan where 
it is endemic, but in Egypt, Manila, and Japan. Cholera is a disease which 
produces a catastrophic diarrhea with resultant dehydration, acidosis, and 
potassium depletion. A discussion of cholera necessarily involves the use of 
superlatives: the numbers who have died of this disease, 66 million in India 
alone during the past two centuries; the amount of diarrhea, up to 26 liters 
per day; the amount of intravenous fluid necessary for replacement therapy, 
up to 126 liters over a 3 -day period; all these features call for superlative 

Although known since ancient times, cholera has assumed pandemic 
form only with the advent in the 19th century of the industrial revolution and 
rapid means of travel. It was the first disease in which parenteral fluid re- 
placement was employed (1837). It was the first in which biochemical studies 
of body fluids were performed (1837), and the first in which acidosis was recog- 
nized (1911). Cholera has been responsible for more quarantine regulations 
than any other disease. The U.S. Navy has participated in study of cholera 
through its NAMRU-3 during the Egyptian epidemic of 1947, and NAMRU-2 
during epidemics in Thailand in 1958 and I960. 

Cholera is a water and food-borne infection; where a good water supply 
is available it rarely has a chance to develop. In the matter of a carrier-state, 
much confusion exists. That a person can carry the vibrio more than 3 to 5 
days has never been demonstrated. Where the vibrio hides during the winter 
or between epidemics has not been worked out. The incidence of cholera is 
interesting. It occurs in conjunction with a pattern of deficiency states, para- 
sitism, anemia, and generally poor health. A middle class European, rea- 
sonably healthy, is most unlikely to contract the disease. Therefore, cholera 
is not likely to pose a threat either to tourists or to military personnel. 

Since the cholera organism is limited entirely to the gastrointestinal 
tract, the disease it produces differs from those seen in infections from sal- 
monellosis, Shigella, or other bacilli. Formerly, the profuse diarrhea in 
cholera was thought to result from loosening or lysis of gastrointestinal epi- 
thelium, that the organism caused denudation of the intestinal tract through 
the weeping surface of which copious amounts of water and salts would pour. 
Observations leading to these conclusions, however, were based on postmor- 
tem studies. Agonal or postmortem autolysis could not be excluded. 

In acute cholera, recent biopsy studies in living patients have shown 
intact epithelium. The current concept is that the vibrio produces a toxin 
that inhibits the cellular transport mechanism, particularly the sodium pump. 
In the healthy individual, vast amounts of water and salts surge in and out of 
the intestinal tract. The net flux, of course, is a return of these substances 

12 Medical News Letter, Vol. 43, No. 1 

to the body; most people excrete dry stools. In cholera, resorption of these 
materials is inhibited. It has been postulated that inhibition of active reab- 
sorption of 10% to 20% would result in stool volumes of 15 to 30 liters per day. 

Presentation of certain clinical observation made by the NAMRU-2 
team during the Bangkok epidemic of 1958 is now in order. Prior to the 
arrival of this team, the Thais had been giving vast amounts of saline through 
an old fashioned gum-rubber apparatus. A patient depicted receiving such an 
infusion showed a commonly observed sign of infection— a sarong soaked in 
the back. Quantitative methods of study were then devised, one patient a day 
being selected. Each such patient was provided with an intravenous infusion, 
a bladder catheter, and a rectal tube. 

The greatest problem in cholera is the diagnosis and treatment of 
dehydration. A typical patient, a woman of 25, showed before treatment with 
sunken, dull, listless eyes, hollow cheeks, lips pulled back over the teeth, 
shrinkage of the thenar eminence, and shrunken hands. After treatment, the 
patient appeared plump and handsome, replacement of 4 liters of fluid having 
made this difference. Clinical detection of dehydration is not difficult; the 
condition is obvious. The problem is to quantitate the degree of fluid replace- 
ment necessary. The most successful method of assessment in this study was 
estimation of the plasma protein content by the use of the copper sulphate de- 
termination of specific gravity of plasma. The apparatus is portable, easily 
set up, and readily usable by anyone after a moderate amount of experience. 

Plasma rather than whole blood determinations were chosen because 
many of the patients were anemic. After estimation of specific gravity, an 
empirical formula could be used to determine the amount of fluid replacement 
needed (200 ml N/S for each 0. 001 increase in specific gravity above 1. 025). 
Comparison by the Evans blue dye method of measuring plasma volume with 
other methods — including plasma and blood specific gravity, carbon dioxide 
content of plasma, microhematocrit, and gravimetric determination of plasma 
electrolytes — showed the best correlation to be with plasma specific gravity. 
Allowance for insensible water loss in a hot climate with high humidity proved 
essential. Treatment of acidosis, also, was extremely worthwhile as was 
replacement of potassium. Use of the method outlined reduced the mortality 
rate from cholera from 15% in 1958 to 3% in the following year. 

Cholera will continue as long as poverty, malnutrition, ignorance, 
and superstition exist. Immunization does not appear to be the answer to this 
disease. Until all of the factors responsible for the propagation and control 
of cholera have been controlled, proper aid in time of epidemic would better 
be rendered by rushing supplies of intravenous solutions into the infected area 
than by supplying vaccine. 

Medical News Letter, Vol. 43, No. 1 13 

Leishmaniasis - with Emphasis upon Recent 
Epidemiological Findings 

Donald Heyneman PhD, Associate Research Parasitologist, University 
of California Medical Center. 

In leishmaniasis, as in amebiasis, the difference between infection and disease 
must be emphasized. Leishmaniasis is far more widespread than high mor- 
tality figures reported in disease would indicate. It is a complex involving 
extremely large numbers of factors, not simply an etiologic agent in a given 
patient. An interaction between sociologic, biologic, and ecologic factors 
sometimes produces disease; at other times, a protective situation with a low 
level of disease. Epidemiologic factors in leishmaniasis must include human 
malnutrition, the presence of wild animal reservoirs and a variety of insect 
vectors, and sociologic considerations involving infected human beings, such 
as extreme poverty and tribal habits. 

Leishmaniasis embraces a complex of diseases caused by three organ- 
isms that cannot be differentiated morphologically. L. donovani, L. tropica, 
and L. braziliensis . The first is generally considered the agent for kala-azar, 
visceral leishmaniasis. This can be further subdivided into a number of 
disease entities. In the Mediterranean basin, infantile leishmaniasis affects 
mostly the population under 3 years of age, probably producing a high degree 
of immunity which makes the disease rare in older age groups. The dog is 
the common reservoir. The adolescent form occurs in India where man 
himself is the likely reservoir. In South America, -a moderate form occurs 
in which the dog and wild foxes serve as reservoirs. There is a peculiar form 
of post-kala-azar leishmanoid which occurs only after infection, after treat- 
ment. Papular skin eruptions appear perhaps a year later which may contain 
demonstrable organisms and which are highly resistant to treatment. Such 
disease is easily transmissible, even mechanically by stable flies. Another 
variety of leishmaniasis in addition to those noted may be found in Russia. 

The cutaneous form caused by L. tropica is known variously as 
"Oriental sore" or "Aleppo boil. " It may be divided into the classical dry 
type, urban in distribution, chronic, with little ulceration, and the moist type 
common in Russia, rural, rapidly productive of weeping ulcers with sharp 
edges. Dogs are susceptible to the first type; direct transmission mechani- 
cally may occur in the second, although sand flies cannot be excluded. 

American leishmaniasis, caused by L. braziliensis , produces a hide- 
ously deforming disease called "espundia" in the Brazilian rain forest. The 
organisms occupy the nasal spaces, destroying nasal cartilage, the lips, and 
pharyngeal areas. A more moderate form in the Peruvian mountains is "uta. " 
Among the gum pickers, another form, "chiclero, " chronically affects the 
pinna of the ear. 

The vectors in all three families of diseases are sand flies, tiny midges 
belonging to the genus Phlebotomus . They are voracious blood-suckers of 
worldwide distribution found wherever there is sufficient moisture. This 

14 Medical News Letter, Vol. 43, No. 1 

condition may be satisfied in cracks in ground or walls or in garbage heaps, 
the micro-habitat, which are quite specific for the species. There is a close 
association between the clinical form of the disease produced and capacity of 
the individual species of fly to transmit it. Each subtype of leishmaniasis 
is carried by a specific vector. 

Leishmania donovani bodies, typically shown in spleen impression 
smears, are ordinarily intracellular and possess no flagellum. Found in 
macrophages, they cluster in cytoplasmic spaces within monocytes. A small 
black dot, the parabasal body, is found near the eccentric nucleus. In the 
intestinal tract of the sandfly is found the leptomonad form, elongate with a 
central nucleus. How these form, where they concentrate, and the rate of 
development determine whether the fly is a suitable vector. 

The clinical picture in kala-azar ("black-sickness") is striking. 
Strengthening of color and brightness around the forehead gives the disease 
its name. Advanced cases show extreme emaciation. In the Sudan, swelling 
of the inguinal nodes is observed. Diurnal fever, lassitude, leukopenia, and 
moderate to extreme anemia occur. The outstanding feature of the disease, 
however, is splenomegaly. Growing at the rate of one inch a month, the 
organ may fill the abdominal cavity. Liver enlargement occurs at a slower 
rate. In summary, proliferation of L. donovani in the reticuloendothelial 
system, primarily in the spleen, causes enormous proliferation of splenic 
tissue; the liver is involved to a lesser degree. Any organ in the body except 
the central nervous system may, however, be affected. 

A characteristically violent outbreak of kala-azar occurred in the 
Sudan in 1952. Of 18, 000 people estimated to have been infected, some ten 
thousand died. Whole villages were wiped out. Inhabitants of others took to 
flight. Witch doctors refused to treat the victims. Representatives of the 
World Health Organization, invited by the Sudanese government to survey the 
area, recommended intensive research, especially with respect to transmis- 
sion of the disease and to epidemiologic factors involved. A special leish- 
mania project under the aegis of NAMRU-3 resulted. The project was aimed 
at finding a vector, an animal reservoir, and a mode of transmission; none 
of these objectives had been achieved, despite intensive effort, during the 
preceding half century. 

First, an effective survey of the sandfly population was achieved by 
catching flies on deliberately exposed people, grinding them up, and inocula- 
ting them aseptically into hamsters. The hamsters became sick and died of 
leishmaniasis. The organism was carried in culture. One fly, Phlebotomus 
orientalis, of the forty-two species in the Sudan, was found to be infected. 
The vector common in the Mediterranean was present but not infected. 

Spleen impressions from livers of three kinds of infected rats con- 
tained leishmania which "took" in hamsters. Rodentine reservoirs appeared 
to be potential sources of epidemics. Phlebotomus orientalis epidemics occur 
every 6 or 7 years due to fluctuations of rat populations, concentration of sand- 
flies, and proximity to human beings. Since man harbors the organism in the 
nasal mucosa and excretes it in urine and feces, possibility of direct trans- 
mission as in pneumonic plague must be considered. 

Medical News Letter, Vol. 43, No. 1 15 


BUMED NOTICE 6310 19 November 1963 

From* Chief, Bureau of Medicine and Surgery 

To: Convening Authorities of Medical Boards and Boards of Medical Survey 

Subj: Reports of Boards of Medical Survey and Medical Boards; 
recording of disease and injury codes 

Ref : (a) Department of Defense Disease and Injury Codes (NAVMED P-5082) 

(b) Standard Nomenclature of Diseases and Operations (SND) 

(c) Joint Armed Forces Statistical Classification and Basic 
Diagnostic Nomenclature of Diseases and Injuries With a 
List of Surgical Operations (NAVMED P-1294) 

(d) BUMEDINST 6310.5, Subji Implementation of Department of 
Defense Disease and Injury Codes (DDDIC) 

1* Purpose . To direct activities submitting Reports of Boards of 
Medical Survey and Reports of Medical Boards to use diagnoses and 
code numbers from the Department of Defense Disease and Injury Codes. 

2. Background. The Bureau has noted that many of the subject reports 
fail to show diagnoses in nomenclature of references (a) or (b) with 
corresponding code numbers from reference (a). This results in con- 
siderable, unnecessary expenditure of time and effort on the part of 
Bureau personnel in researching and assigning code numbers. 

3» Action . Addressees are directed to insure that the subject reports 
set forth the diagnoses and code numbers in terms of reference (a). 
Nomenclature and code numbers drawn from reference (c) shall not be 
used, as directed by reference (d). 

4. Cancellation . This Notice is canceled upon noting the contents 
thereof, and no later than 31 January 1964. 


Additional copies of this directive may be obtained from: 
Bureau of Medicine and Surgery, Code 4522. 

16 Medical News Letter, Vol. 43, No. 1 

Immunization Information for International Travel - 
1963-1964 Edition 

The booklet, Immunization Information for International Travel, revised in 
June 1963, has been published. Previous issues of the booklet and any 
addendums should be destroyed,. 

Changes in immunization requirements occurring before the next issue 
of the booklet will continue to be listed under the item, International Notes - 
Quarantine Measures , in the weekly Morbidity and Mortality Report, pub- 
lished by the Communicable Disease Center, Atlanta 22, Ga. Persons not 
receiving this report may write to that office to be placed on the mailing list. 
Copies of the booklet may be obtained from the Superintendent of Documents, 
Government Printing Office, Washington, D. C. 20402, at 35£ a copy. There is 
a discount of 25% for 100 or more copies delivered to the same address. 

The principal revisions are included in Section 5 which contains the 
most current information on the immunization requirements for entrance to 
countries. New yellow fever vaccination centers to which the public may be 
referred have been added to Section 6. — DHEW PHS. 

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International Certificates of Vaccination 

Reports have been received by the Division of Foreign Quarantine of the U. S. 
Public Health Service that many persons traveling abroad have their immuni- 
zations recorded either on a physician's prescription blank or have the inter- 
national vaccination document improperly completed. Consequently, in some 
instances, these travelers are being detained at international ports of entry. 

International travelers should be warned that smallpox and cholera 
vaccinations, when required for international travel, must be recorded on 
the World Health Organization approved International Certificates of Vaccina- 
tion Form; all information must be complete including the "Approved Stamp, " 
which is the stamp of the local or State Health Department. Other approved 
stamps include those of the Department of Defense, Public Health Service, 
and those special stamps issued by the latter agency. 

— M & M Wkly Rep DHEW PHS 12(45): 384, 15 November 1963. 

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Drug Literature Report. The Senate Committee on Government Operations 
has published the report on the Nature and Magnitude of the Drug Literature 
which the National Library of Medicine prepared at the request of the Sub- 
committee on Reorganization and International Organizations, This Com- 
mittee Print is entitled Drug Literature ; copies are available at 65£ from the 
Superintendent of Documents, U.S. Government Printing Office, Washington, 
D. C. 20402. —National Library of Medicine News, DHEW PHS. 

Medical News Letter, Vol. 43, No. 1 17 

Trachoma Virus Actually a Bacterium 

Scientists at the Naval Medical Research Institute, Bethesda, report in the 
November 22 issue of Science that trachoma "virus" utilizes glucose, a 
sugar. This is a property common to almost all bacteria but not to viruses. 
Bacteria produce their own energy and manufacture their own cell substance. 
Glucose is the most common source of energy for man as well as bacteria. 
Viruses, on the other hand, "direct" the cells of the host in which they grow 
to do this work for them. 

Although the microorganism causing trachoma is found within host 
cells, it is now apparent that this disease agent possesses the attributes of a 
bacterium rather than a virus. Although the agent of trachoma has not yet 
been grown without host cells, the present finding is believed to be the first 
important step in that direction. Growing the agent of trachoma in a chemical 
medium without cells would greatly aid diagnostic procedures and improve the 
production of vaccines. 

Two scientists of NMRI are responsible for this work. They are 
Richard Ormsbee, guest scientist from the National Institutes of Health in 
Hamilton, Montana, and Emilio Weiss, Deputy Director of the Department of 
Microbiology of NMRI. Both men are known for other work oh the properties 
of microorganisms that lie at the border line between viruses and bacteria. 
This is their first major venture in the field of trachoma. 

Trachoma is a disease of the eye that often blinds its victims. It is 
estimated that it affects 400 million persons, mostly in tropical zones of the 
world. The agent of trachoma was cultivated in the cells of developing chicken 
embryo for the first time in 1955. Since then, scientists throughout the world 
have isolated strains and produced and tested vaccines. The U. S, Navy has 
taken the lead in this investigation at both the Naval Medical Research Unit 
No. 2 in Taipei, Taiwan, and the Naval Medical Research Institute in Bethesda, 
Md. —NMRI NNMC, Bethesda, Md. 

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Missile Emergency Teams Formed 

Point Arguello, Calif. , NAVNEWS, 15 November 1963. Missile Accident 
Emergency Teams (MAETs) to assist in event of missile fires, explosions', 
or missile impacts have been formed at the Naval Missile Facility here. 
MAET teams will stand by during fueling, defueling, ordnance installations, 
static firings, and missile launches at NMF. 

The teams were established by the Range Department under the Range 
Officer and, during missile operations, the MAET is under operational con- 
trol of the Ground Safety Officer. 

Although the MAET composition varies with the types of operation 
being supported, a typical team might consist of the units as listed on the 
following page: 

18 Medical News Letter, Vol. 43, No. 1 

One MAET Commander with radio-controlled vehicle 

One Pad Safety Officer 

Two four-man fire companies with fire trucks 

Two sentries with vehicles 

Two corpsmen with ambulances 

One heavy equipment operator with a bulldozer on a truck 

One 10 -man fire fighting team of Navy enlisted men with a 

4-wheel drive truck 
One photographer with equipment 
Two helicopters and crews 
One explosive ordnance team with vehicle 

When the MAET team assembles, some come dressed in strange costumes. 
The hospital corpsmen and firefighters wear rubber acid suits to protect 
them from noxious vapors and fluids. Special oxygen breathing apparatus 
is used with the acid suits. 

MAET teams on the scene could cut off a danger area, put out fires, 
treat personnel, properly dispose of explosives, evacuate personnel, vent 
high pressure vessels, maintain security, maintain communications, and 
provide documentary photography during any emergency. 

How Indianapolis Hospitals Met the Blast Emergency 

Shortly after 11:00 p.m., October 31, 1963, a gas explosion ripped the 
Coliseum and flooded Indianapolis hospitals with 385 blast victims, many of 
them suffering from shock and multiple injuries. Indianapolis hospitals have 
met emergency demands on their resources before, but this catastrophe was 
the first real test of their total resources. All of the local hospitals, the 
city agreed, performed magnificently in handling the emergency. 

At a post-disaster critique held 5 days after the explosion, hospital 
representatives said that their hospitals were not officially notified of the 
disaster before patients began arriving. Telephone lines soon became so 
clogged with calls for information that they were useless for communication 
between hospitals and disaster agencies. State and local police radios became 
the major means of communication, but these were not available to hospitals. 

Among the consequences of lack of adequate communication were the 
following: (1) Hospitals were not notified promptly of the disaster, so were 
harder pressed to cope with patients than they otherwise would have been. 
(2) Proper distribution of patients could not be made because rescue workers 
and physicians at the Coliseum could not communicate with hospitals concern- 
ing how many blast victims they could accept. (3) Hospitals could not learn 
the extent of the disaster so did not know whether to launch a full-scale 
disaster effort including recalling staff and personnel from home. (Hospitals, 
J Amer Hosp Assn, November 16, 1963) From: Civil Defense Review, Council 
on National Security, AMA 13(6):7, December 1963. 

Medical News Letter, Vol. 43, No. 1 19 


International Naval Medical Conference 

The Second Conference of the Surgeons General, Navies of the Americas, and 
the First Mexican Congress of Naval Medicine were held recently in Mexico 
City. Represented were the navies of Argentina, Brazil, Canada, Colombia, 
Chile, Ecuador, United States of America, Guatemala, Mexico, Paraguay, 
Peru, Uruguay, and Venezuela. Scientific program participants from the U. S. 
Navy included RADM E. C. Kenney MC USN, Surgeon General; RADM R. B. 
Brown MC USN, Assistant Chief of Bureau for Personnel and Professional 
Operations; CAPT R. E. Mitchell MC USN, Research Assistant for Cardiology, 
U.S. Naval School of Aviation Medicine, NAMC, Pensacola, Fla. ; CAPT H. G. 
Green DC USN, Head of Oral Surgery Department, U. S. Naval Dental School, 
NNMC, Bethesda, Md. ; CDR J. H. Schulte MC USN, Director, Submarine 
Medicine and Special Weapons Defense Divisions, BuMed; CDR E. W. Bird 
MC USN, Head of Audiovisual Training Branch, BuMed; and CDR J. E. 
Rasmussen MSC USN, Acting Director, Behavioral Sciences Department, 
Naval Medical Research Institute, NNMC, and Head of Research Coordination 
Section, Neuropsychiatry Branch, BuMed. 

The Conference was sponsored by the President of the Republic of 
Mexico, Adolfo Lopez Mateos ; the Secretary of the Mexican Navy, C. Almir- 
ante C. G. Manuel Zermeno Araico; and the Surgeon General of the Mexican 
Navy, Contralmirante S. N. M. C. , Rafael Vargas Salazar. This jointly con- 
ducted conference was a great success. Members of the United States dele- 
gation found the assemblies of leaders in naval medicine of the Americas to 
be mutually beneficial and rewarding for the exchange of ideas, revelation of 
areas and methods for management improvement in administration, and for 
promotion of modern methods of preventive medicine and patient care in mil- 
itary populations. The agenda was skillfully planned as were the several ex- 
cellent programs of social recreation during the week of the conference. 

* # sjs * Sj! Jji 

NAMRU No. 2 - Its Historical Background 
and 1963 Reunion 

The NAMRU idea was fostered by the late Vice Admiral Ross T. Mclntire 
in 1942. He requested that Doctor Thomas M. Rivers, then Director of the 
Rockefeller Institute's Department of the Hospital, take leave of absence from 
his post to inspect the Southwest Pacific Area for the Navy in order to deter- 
mine the number of casualties resulting from tropical diseases. 

Upon his return, Doctor Rivers reported that "malaria and other trop- 
ical diseases were causing as many Pacific casualties as were bullets. " 
Early in 1943, he organized Naval Medical Research Unit No. 2 with the pur- 
pose of combating the little known tropical diseases by research methods. 

20 Medical News Letter, Vol. 43, No. 1 

The unit numbered fewer than three hundred officers and enlisted men. 
The site chosen for this field medical research laboratory — the first of its 
kind in world military history — was Guam. Arriving at this Pacific island 
late in 1944, the handpicked group of personnel "cleared the area, built, and 
maintained (for several years) an efficient field laboratory. " Trained teams 
accompanied many invasion units throughout the Pacific Area and returned to 
their Base on Guam for technical evaluation and development of their findings. 

Following the years of World War II, many of the original personnel 
communicated with one another. In March 1962, through the efforts of Doctor 
Robert H. Jackson and P. Bruce Brockway Jr, a questionnaire was sent to 
known former members of the Navy-Rockefeller Unit concerning advisability 
of holding a reunion. The replies were enthusiastic. After months of inten- 
sive planning, the first Reunion of NAMRU No. 2 was held 25 - 26 October 
1963 in Washington, D. C. Many returning former members of the unit, their 
wives and guests, the Medical Department of the United States Navy, Members 
of Congress, and others contributed greatly to the success of the 1963 Reunion. 

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New Billet for Research and Development . CAPT Carl E. Pruett MC USN, 
who has been on loan for the past year to the Director of Defense Research 
and Engineering as a staff specialist in Medical and Biological Sciences, has 
returned to the Navy. On 15 October 1963, he assumed duties as Assistant 
for Medical and Allied Sciences, to the Deputy Chief of Naval Operations 
(Development). This position has been established as part of the Navy plan 
to give more consideration to problems of Man in the Weapon System during 
Research and Development Phases . 

Field Tests of New Antimalarial Drug . Field testing of the new long -acting 
antimalarial drug, C1501, will begin in Pakistan probably early in 1964. On 
a recent visit to Pakistan, Dr. G. Robert Coatney, Chief of the Laboratory 
of Parasite Chemotherapy, National Institute of Allergy and Infectious Dis- 
eases, completed testing arrangements with Dr. M. K. Afridi, Consultant on 
malaria to the Pakistani government. They were assisted by representatives 
of University of Maryland's International Center for Medical Research and 
Training with facilities at Lahore, Pakistan. The field trial will extend over 
approximately a period of 30 months. 

A single injection of the new drug continuedto protect volunteers nearly 
a year later even though they were bitten by heavily infected mosquitoes at 
monthly intervals according to initial results of testing reported by Dr. Coat- 
ney at the annual meeting of the American Society of Tropical Medicine and 
Hygiene in November 1962. Volunteers not given the drug who were bitten 
by the same mosquitoes "invariably came down with malaria. " 

—Public Health Report, DHEW PHS 78(11):976, November 1963 

$ $ sje $ $ $ 

Medical News Letter, Vol. 43, No. 1 21 

Naval Medical Research Reports 

U. S. Naval Medical Research. Unit No. 3 Malakal Subunit, Cairo, Egypt 

1. Leishmaniasis in the Sudan Republic. 15. An Outbreak of Kala Azar in 
the Khor Falus Area, Upper Nile Province: MR 005.09-1603. 1, 
October 1963. 

2. Ecological Studies of Phlebotomus Sandflies in the Paloich Area, Upper 
Nile Province, Sudan: MR 005. 09-1605, October 1963. 

U.S. Naval Medical Research Unit No. 4, U.S. Naval Training Center , 

Great Lakes, 111 . 

1. Comparative Effectiveness of 1/2 ml and 1 ml Doses of Adenovirus 

Vaccine on Respiratory Disease in Navy Recruits: MR 005. 09-1203. I, 

September 1963. 

U.S. Naval Air Development Center, Aviation Medical Acceleration Labora - 
tory, Johnsville, Penna . 

1. Eye Melanin Free Radical Kinetics and Mechanism in Relation to the 
Roginsky-Zeldovich (or Elovich) Equation and the Adsorption of Oxygen by 
Semiconductors: MR 005. 13-0002. 7 Report No. 23, September 1963. 

2. Pilot Biomedical and Psychological Instrumentation for Monitoring Per- 
formance During Centrifuge Simulations of Space Flight: 

MR 005. 13-6002.4 Report No. 3, October 1963. 

3. The Composition of Mitochrome and Cytochrome Oxidase from Rat Liver 
Mitochondria: MR 005. 13-0002. 7 Report No. 22, October 1963. 

U.S. Naval Medical Field Research Laboratory, Camp Lejeune, N. C . 

1. Effect of Postburn Serum on In Vitro Respiration of Normal Myocardium: 
MR 005. 12-7020. 1.4, September 1963. 

2. Early Changes in Serum Enzymes in the Rat Following Burn Trauma: 
MR 005. 12-7020. 1.5, September 1963. 

3. Influence of Body Armor Coverage and Weight on Performance of the 
Marine while Performing Certain Simulated Combat-Type Tasks: 
MR 005. 12-7010. 1. 17, November 1963. 

U.S. Naval Submarine Base, U.S. Naval Medical Research Laboratory , 
New London, Conn. 

1. Difference Between Real and Apparent Visual Movement: 
MR 005. 14-1001-1.30 Report No. 402, May 1963. 

2. Lighting Survey of USS SEA ROBIN (SS407) Memorandum Report 
No. 63-9: MR 005. 14-1100-1. 13, June 1963. 

3. Submarine Psychiatry: MR 005. 14-2100-1. 12 Report No. 409, 
August 1963. 

4. Lighting Survey of USS SUNBIRD (ASR-15): MR 005. 14-1100-1. 14 
Memorandum Report No. 63-11, August 1963. 

5. Relation of Perstimulatory Adaptation to Other Short-Term Threshold- 
Shifting Mechanisms: MR 005. 14-1001-2. 13 Report No. 407, August '63. 

22 Medical News Letter, Vol. 43, No. 1 


Diagnosis and Prevention of Cerebrovascular Accidents 

Ben Eiseman MD, Frank Spencer MD, and Stephen F. DachiDMD MSD, 
University of Kentucky, Lexington, Kentucky. Oral Surgery, Oral Medicine, 
and Oral Pathology 16{10): 1174-1179, October 1963. 

This report, by faculty members of the University of Kentucky, Colleges of 
Medicine and Dentistry, brings attention to a symptom often observable first 
in the dental office, which may precede cerebrovascular accidents. 

During dental examination and treatment, it frequently becomes neces- 
sary to rotate the patient's head far to one side for adequate exposure. Oc- 
casionally such rotation produces temporary neurologic signs, such as con- 
fusion, dizziness, blurring of vision, slurred speech, and unconsciousness. 
Any patient with such symptoms should be referred for medical consultation, 
since additional tests are required to determine if these, as observed by the 
dentist, are indicative of brain hypoxia. If so, is this a result of diminished 
blood flow through a diseased carotid artery that has become compressed by 
rotation of the head. 

Attention of Medical News Letter readers is invited to the original arti- 
cle to become familiar with the symptoms, physiology involved, and the possi- 
bility of success in treatment when diagnosed early. 

$ $ sjc aje sts ♦ 

Current Evaluation of Fluoride Therapy * 

J. C. Muhler, School of Dentistry, Indiana University. J Am Pharm A 
3: 133-135, March 1963. From Dental Abstracts 8(10): 608-609, October 

The uncontrolled dissemination of fluorides is a cause for increasing concern 
for the Food and Drug Administration and dental scientists. Currently, three 
methods of using fluorides are considered safe by most dental scientists. These 
are: (1) fluoridation of the public water supply; (2) topical application; and (3) 
a stannous fluoride -calcium pyrophosphate dentifrice. 

Other methods of application, such as vitamin supplements and prenatal 
products, should be discouraged until conclusive proof is provided of their 
benefits and possible harmful effects. 

Medical News Letter, Vol. 43, No. 1 23 

Effect of Orally Administered. Neomycin* 
on Absorption of Penicillin V 

Samuel H. Cheng and Arthur White, University of Louisville School of 
Medicine, Louisville, Kentucky. JAMA 267: 1296-1297, December 20, 1962. 
From Dental Abstracts 8(8): 505, August 1963. 

Studies of the absorption of penicillin V (potassium phenoxymethyl penicillin) 
were performed on five normal, healthy young male medical students before, 
during, and after the daily oral administration of 12 Gm of neomycin (in the 
dose of 3. Gm four times a day). Penicillin activity in urine and blood was 
assayed by a cylinder -plate method using Sarcina lutea as the assay organism. 

The oral administration of neomycin reduced serum penicillin concen- 
tration and urinary recovery of penicillin to less than 50 per cent of control 
values. A return toward normal values was apparent six days after the ad- 
ministration of neomycin was discontinued. 

The absorption of penicillin V is so reduced during the oral adminis- 
tration of neomycin that the therapeutic efficacy of the penicillin may be se- 
verely compromised. 

* These articles are copyrighted by the American Dental Association. 
Reprinted by permission. 

# * # % * * 

Personnel and Professional Notes 

National Child ren's Dental Health Week . All Dental Officers and Technicians 
are encouraged to participate in the forthcoming National Children's Dental 
Health Week. Many facilities already have excellent annual programs designed 
to work with dependents, community school systems and PTA groups. They 
have set a good pattern for all to follow. 

The preventive dentistry film Oral Hygiene MN 8952 , supplemented 
with locally made posters, is a valuable aid to those personnel selected to 
present talks to children and/or parents. Additional material may be procured 
from the Bureau of Dental Health Education, ADA, 222 East Superior Street, 
Chicago, Illinois, 60611. Many of the drug and toothpaste manufacturers have 
national programs planned to assist dental societies and dentists in preventive 
dentistry. For the address of your local representative for programs distributed 
by such companies, contact the Professional Services Division, P.O. Box 599, 
Cincinnati, Ohio. 

As successful programs are organized please inform the Dental Division, 
Bureau of Medicine and Surgery, so appropriate recognition may be made and 
service -wide distribution of ideas accomplished. In this way' the Dental Division 
can perform effectively as a distribution center to help all personnel to improve 
their preventive dentistry efforts. 

24 Medical News Letter, Vol. 43, No. 1 

Preventive Dentistry Course Held at Naval Dental School . Dental officers of 
the Army, Navy, Air Force, Public Health Service, and Veteran's Adminis- 
tration, along with 18 Commanding Officers of Naval Reserve Dental Compa- 
nies , attended a course on "Preventive Dentistry" at the Naval Dental School, 
Bethesda, Maryland. The five day course, which commenced on 28 October 
1963, emphasized prevention of the two most common oral pathological prob- 
lems, dental caries and periodontal disease by recognition and elimination of 
contributing factors. The dental health of military personnel along with the 
means and personnel available to treat clinically evident cases was discussed 
as an important approach to a practical application of preventive dentistry 
today, and in the future. 

Representatives of the military, university, and public health institu- 
tions conducted the course, which included: Dr. Basil G. Bibby, Eastman 
Dental Dispensary; Dr. Philip Jay, University of Michigan; Dr. Joseph C. 
Muhler, Indiana University; Dr. Harry W. Bruce, U.S. Public Health Service; 
Drs. Norman Littleton, Paul Baer, David Scott, Paul Keyes, Edward Hampp 
and Robert Fitzgerald of the National Institutes of Health; COL George Burnett 
DC USA and COL Russel Sumnicht DC USA: CAPT Angus W. Grant DC USN, 
CAPT Theodore R. Hunley DC USN, CAPT Peter F. Fedi DC USN, and CAPT 
Frank Grossman DC USN, of the Naval Dental School. The Director of the 
course was CAPT Gordon H. Rovelstad DC USN. CAPT Arthur R. Frechette 
DC USN is Commanding Officer of the Naval Dental School. 

Dental Reserve Officers Attend BUMED Seminar. Eighteen Dental Reserve 
Officers from the Third, Fourth, Fifth, Sixth, Eighth, and Ninth Naval Districts 
attended a seminar conducted by the Dental Division, Bureau of Medicine and 
Surgery, 28 October to 1 November 1963. The seminar, which was conducted 
at BUMED with field trips to the Naval Dental School and the Bureau of Naval 
Personnel, was designed to acquaint commanding, executive, and training 
officers with the administrative and technical considerations of dental reserve 
companies. A similar course will be presented for Dental Reserve Officers of 
West Coast Naval Districts, 7-9 September 1964. 

List of Officers Attending 
Dental Reserve Commanding Officers' Seminar 

CAPT Evert A. Archer DC USNR, Lake Bluff, Illinois 

LT George R. Butler Jr. DC USNR, Atlanta, Georgia 

LCDR Ferdinand C. Cerine DC USNR, Springfield, Va. 

CDR Loren W. Curtis DC USNR, Peoria, Illinois 

LT Frederic Custer DC USNR, Philadelphia, Pennsylvania 

LT Ted E. Dyer DC USNR, Liberty, Missouri 

LCDR Albert O. Grant DC USNR, Morristown, New Jersey 

LCDR John R. Gunderson DC USNR, Homestead, Florida 

CDR Joseph W. Johnson Jr. DC USNR, Waukee, Iowa 

CDR Andrew M. Linz DC USNR, New York, New York 

Medical News Letter, Vol. 43, No. 1 25 

CAPT Jack E. Myers DC USNR, Dallas, Texas 
CDR Albert G. Paulsen DC USNR, Falls Church, Va. 
CDR William C. Perkins DC USNR, Dallas, Texas 
CAPT Lowery D. Reaves DC USNR, Dearborn, Michigan 
CAPT Robert B. Smythe DC USNR, New Orleans, Louisiana 
LT James M. Sweeney DC USNR, Shawnee, Kansas 
CAPT Robert W. Wiethoff DC USNR, Wayasta, Minnesota 
CDR Nathan R. Callaghan, Jr. DC USNR, Iowa City, Iowa 

Joint Training Program. The dental officers at the Naval Air Station, Atsugi, 
Japan and Army dental officers at Camp Zama, Japan have scheduled bi- 
monthly training programs. The first program was presented at Atsugi, on 9 
December 1963 and CAPT Juda DC USAF, Orthodontist at Fuchu Air Station, 
presented a paper on the topic "Orthodontists as Related to the General Prac- 
titioner. " 

These combined programs are included in the weekly training schedule 
routinely presented at Atsugi, under the direction of the dental department 
training officer LCDR T. E. Stump DC USN. CAPT Norman B. Shipley DC 
USN, is head of the Dental Department, NAS, Atsugi, Japan. 

Ann ual Session of Military Surgeons . Dental officers participated in the 70th 
Annual Meeting of the Association of Military Surgeons, 4-6 November 1963, 
which was devoted to the theme, "Medical Research Today -Military Resource 
Tomorrow. " CAPT William E. Ludwick presented a report on "Increased Use 
of Specially Trained Dental Technicians. " CAPT William R. Stanmeyer ana- 
lysed the "Educational Trends and Problems in the Federal Dental Services. " 
CAPT Carl A. Ostrom served as Chairman of the Dental Section. 

Pr eventive Dentistry in Iceland . The following article appeared as one of a 
series presented by the station newspaper in cooperation with the Dental Depart- 
ment at the U. S. Naval Station, Keflavik International Airport. This series of 
preventive dentistry articles is one phase of their outstanding program to help 
improve the oral health of the personnel in that area. CAPT George R. Reynolds 
DC USN is the head of the Dental Department: 

How's your dental IQ? If it is high, chances are your dental problems 
are few and you -will keep your teeth for a lifetime. If low, you ought to see 
your family dentist for the care and instruction he can give which will remedy 
the situation. Test yourself and see how you do. Decide which of these items 
are fact and which are fable. 

1. Pregnancy increases tooth decay. 

2. Teeth decay because they are soft. 

3. The six-year molar is the last of the baby teeth. 

4. The best times to brush your teeth are before breakfast and before 
going to bed. 

5. Drinking lots of milk will help prevent tooth decay. 

6. A decayed tooth will sometimes heal itself. 

26 Medical News Letter, Vol. 43, No. 1 

7. Some toothpastes can prevent all tooth decay. 

8. Cutting down on sweets helps prevent tooth decay. 

9. Fluoridation of public water supplies is the best way of preventing 
tooth decay for large groups of people. 

Of these statements, the first seven are fables, the last two are fact. Here's 
why the first aren't true: 

1. If tooth decay increases during pregnancy, it is probably because of 
poor mouth hygiene or more eating of sweets rather than direct cause 
and effect relationship. 

2. Teeth vary little in hardness, and the slight difference has nothing to 
do with decay. 

3. "Six year" molars are permanent teeth. 

4. Brushing is most effective immediately after eating. Decay starts 
within 15 minutes. 

5. Milk is a good food, but its main dental value is in building teeth before 
they erupt. It will not prevent decay in teeth already erupted. 

6. A decayed tooth can only get worse, unless it is treated by your family 

7. No toothpaste by itself can prevent all decay. However, there is one 
stannous fluoride toothpaste now marketed which has been recognized 
by the American Dental Association as effective against decay when 
used as part of an overall program of oral hygiene, proper diet, proper 
brushing, and regular visits to the dentist. 

Dental Service Report, DP Form 477-1 . All responsible dental officers at each 
separate command are reminded that the Dental Service Report, DD Form 477-1 
(Equipment and Facilities Supplement) shall be submitted on 1 January of each 
year. The original shall be addressed to BUMED, one copy to the Field Branch 
BUMED, 3rd Avenue and 29th Street, Brooklyn 32, N. Y. , and one copy to the 
reviewing officer. In accordance with Advance Change 14-1, Manual of the 
Medical Department, line 9 of this report should indicate air turbines as sepa- 
rate equipment items regardless of whether they are attached to and accounted 
for as part of the operating unit. 

Naval Reserve Dental Company 3-2. The appointment of CAPT Daniel F. Tobin 
as the new Dean of the Seton Hall School of Dentistry recently prompted an 
analysis of the professional accomplishments of the members of the Naval 
Reserve Dental Company 3-2. The Company is made up of 37 officers. Six of 
these officers are Fellows of the American College of Dentists; four areDi- 
plomates of American Boards, two in Orthodontia, one in Prosthodontia, and 
one in Oral Surgery. Ten members belong to specialized dental organizations 
such as the American Society of Oral Surgeons and the Northeastern Orthodontia 
Society; twelve are Fellows of the New York Academy of Dentistry, including 
the current president, CDR Robert W. Northrop. 

Medical News Letter, Vol. 43, No. 1 27 


Acute Chlo rob romom ethane Toxicity 

CAPT Harvey R. Rutstein MC USAF, Department of Surgery, Mount Sinai 
Hospital, N. Y. Archives of Environmental Health 7(4): 440-444, October 

During World War II carbon tetrachloride and methyl bromide were widely 
used by both the Allied and German armed forces as fire -extinguishing agents. 
These chemicals are highly toxic. When heated to decomposition carbon tetra- 
chloride emits the fumes of hydrogen chloride, chlorine, and phosgene. Methyl 
bromide decomposes into various toxic halide compounds. The risk of phosgene 
poisoning from carbon tetrachloride decomposition was subsequently proved 
overestimated; however, carbon tetrachloride remains a potentially hepatotoxic 
and nephrotoxic chemical to those suffering from severe exposures to it. Methyl 
bromide is no longer used as a fire -extinguishing agent in this country. 

Toward the end of the war, German scientists introduced chlorobromo- 
methane ("CB") into the military armamentarium as an effective, "less toxic" 
vaporizing liquid fire -extinguishing agent. After the war had ended, Allied 
scientific authorities reinvestigated this chemical and analyzed the results of 
the German experience with it. They found chlorobromomethane to be more 
effective than carbon tetrachloride and less toxic than methyl bromide. It was 
adopted as the secondary agent on all water-foam aircraft fire-fighting appa- 
ratus as an adjunct to the action of the primary agent, mechanical protein 

The problem of chlorobromomethane toxicity has received recent in- 
vestigative attention because of animal exposure studies which have defined 
the toxic potential of the chemical. This fire-fighting agent may eventually be 
replaced by a less toxic substance after further pyrolysis investigation of 
such compounds as dibromodifluorom ethane, bromochlorodifluoromethane, 
and 1, 2-dibromotetrafluoroethane. 

Chlorobromomethane toxicity is rare. Ingestion of the chemical has 
not been reported, and it cannot cause toxicity by skin penetration, although 
bothersome dermatitides have followed prolonged skin contact exposures. 
Toxicity is noticeable after inhalation of concentrated vapors of the chemical. 
Since chlorobromomethane is usually handled in open spaces by those well 
indoctrinated in its toxicity potential, there have been relatively few acute 
poisonings. Reports of these poisonings have been confined to the European 

28 Medical News Letter, Vol. 43, No. 1 

The following cases illustrate the syndrome of "acute chlorobromo- 
methane toxicity" as witnessed in three previously healthy men who were 
exposed to concentrated vapors of the decomposing chemical for short periods 
of time. 

Case 1. A 21-year oldmember of the Pease Air Force Base fire-fighting 
department was summoned at 4:15 p. m, to the scene of an emergency landing 
of a B-47 jet bomber. The aircraft had developed a fuel leakage, and high- 
octane fuel was dripping on the nose landing-gear apparatus. It was feared 
that as the pilot braked the plane, the gear mechanism would overheat and 
ignite the dripping fuel. 

As the aircraft touched the runway the pilot applied his brakes, and 
the bomber came to a grinding halt. The patient approached the plane and began 
to concentrate a steady stream of chlorobromomethane over the hot metal. He 
stationed himself approximately five feet from point of contact of chemical with 
metal. Afterfive minutes in this position, his associates noticed he was swaying 
back and forth, obviously disoriented. They removed him from the scene and 
summoned an ambulance. The patient was taken to the Base Dispensary E- 
mergency Room. During the ambulance ride he lost consciousness. 

Upon his admission at 5 p. m. the vital signs were normal. The patient 
had regained consciousness, but he was drowsy and disoriented. He complained 
of a pounding bitemporal headache, nausea, and stomach cramps. The tips of 
his fingers were numb and cold. He was unable to remember where he had been 
or why. Physical examination was within normal limits except for hyperemia 
of the nasal and pharyngeal mucosae and conjunctival injection. He could not 
maintain his balance. At 5:15 p. m. , while being observed, he lapsed into un- 
consciousness and became apneic. 

The patient was placed in a supine position, and a mechanical airway 
was inserted. Oxygen was started by mask. Manual artificial respiration was 
quickly instituted. The patient received an injection of 250 mg of caffeine and 
sodium benzoate intravenously and 250 mg of the drug intramuscularly. 

After one hour with the above vigorous therapy, the patient began to 
breathe spontaneously, but the respirations were weak. He was given another 
500 mg of caffeine and sodium benzoate by intravenous injection, but within 
five minutes he again was apneic. By sniffing near the patient's mouth, one 
could smell the sweet, acrid vapors of chlorobromomethane audits decomposed 
constituents being expired. The artificial respiration was intensified. General- 
ized muscular twitchings were noticed. Occasional lip cyanosis responded to 
an increased oxygen supply. 

At 7:45 p. m. the patient again began to breathe spontaneously. He re- 
gained consciousness, but he was very drowsy and still disoriented. His blood 
pressure, pulse, and temperature were normal. After several minutes of 
observation it was decided that he could be transferred for admission to a 
nearby hospital. 

At 9 p. m. , while lying in a hospital bed, the patient complained of a 
throbbing bitemporal headache. He had become sufficiently oriented to answer 
questions. Physical examination was within normal limits. The blood pressure 

Medical News Letter, Vol. 43, No. 1 29 

was 100 systolic, 70 diastolic, the pulse was 76 and regular, the temperature 
98.4°F (36. 9C), and the respirations 16. Examination of the blood revealed a 
hemoglobin of 15 gm per 100 ml; the white cell count was 9, 500 with 75% neutro- 
phils and 25% lymphocytes. The urine was normal. The urea notrogen was 20 
mg, the cholestrol 150 mg, the bilirubin (total) 0. 4 mg, and the total protein 
7. 8 gm (the albumin 5. 5 gm, and the globulin 2. 3 gm) per 100 ml. The trans- 
aminase was 44 units, and the alkaline phosphatase 6 Bodansky units. The pro- 
thrombin content was 100%, The cephalin flocculation, thymol turbidity, and 
sulfobromophthalein retention were normal. A chest x-ray was normal. 

During the first 24 hours the patient remained drowsy, and it was dif- 
ficult to rouse him from sleep. Generalized muscular twitchings, resembling 
fasciculations , were prevalent, but the neurologic examination was within normal 

After one week of hospitalization the patient complained only of anorexia 
and lethargy. He had lost four pounds in spite of a nourishing diet. The muscular 
twitchings and mental turbidity had cleared after 48 hours. Because one observer 
thought the liver edge palpable one fingerbreadth beneath the right costal margin, 
a Vim -Silverman needle biopsy was performed. It revealed normal hepato- 
cellular configuration without evidence of toxic change. The patient was dis- 
charged on the 14th hospital day fully fit for military duty. 

Case 2. A 21 -year old firefighter was called to the emergency scene 
with the patient in Case 1. He positioned himself approximately eight feet from 
point of contact of chemical with metal. He began to spray mechanical protein 
foam and water over the chlorobromomethane to prevent "flashback" of fire 
which is common because of the rapid evaporation of chlorobromomethane. 

This patient soon noticed a sweetish, pungent odor which was cold on 
inhalation and seemed to take his breath away. His arms and legs began to feel 
cold and numb. Dizziness ensued, but he remained aware of his environment. 
His eyes began to smart, and his upper respiratory tract mucosae burned from 
the toxic vapors. Mild cephalgia in both temporal regions was noticed. He 
removed himself from the scene and accompanied patient 1 to the Emergency 
Room. Twenty minutes thereafter he began to complain of nausea, a burning 
sensation in his stomach, and a pounding headache bitemporally. 

At 5:30 p. m. , after 30 minutes of unrevealing examination, he fell 
unconscious. There immediately ensued generalized muscular twitchings and 
shaking movements of all extremities to the extent that physical restraint of 
the patient by two corpsmen was required. Oxygen was started by mask for 
fear of respiratory depression, but his respirations remained spontaneous and 
unlabored. Vital signs were normal. He remained unconscious and convulsing 
for two hours in spite of the intravenous injection of 200 mg of diphenylhydantoin 
and 300 mg of sodium phenobarbital. To negate any respiratory depressant 
effect of sodium phenobarbital he was given 500 mg of caffeine and sodium 
benzoate by intravenous injection and 500 mg of the drug intramuscularly. At 
7:30 p.m. he regained consciousness. He was weak and disoriented. The con- 
vulsive movements had abated, and he was deemed fit for transfer to a nearby 
hospital. Respirations had remained good, and his lungs were clear to auscul- 

30 Medical News Letter, Vol. 43, No. 1 

On his admission the temperature was 98. 6°F (37. C), the pulse 88, 
and the respiration 16. The blood pressure was 140 systolic, 88 diastolic. 
Examination of the blood revealed a hemoglobin of 15. 5 gm per 100 ml and a 
white cell count of 10, 500 with 75% neutrophils, 23% lymphocytes, and 2% 
eosinophils. The urine was normal. The urea nitrogen was 18 mg, the total 
bilirubin 0. 8 mg, and the total protein 7. 6 gm (albumin 5. 5 gm, and globulin 
2. 1 gm) per 100 ml. The alkaline phosphatase was 3 Bodansky units, the cepha- 
lin flocculation , thymol turbidity and urobilinogen were normal. A chest x-ray 
was normal. 

A Vim-Silverman needle biopsy performed on the eighth hospital day 
to rule out liver cell damage revealed normal hepatic microanatomy. Repeat 
urine and liver function studies were within normal limits, and the patient was 
discharged to duty on the 14th hospital day. 

Four weeks after exposure to chlorobromomethane vapors the patient 
complained of a sharp, intermittent left precordial pain for which no etiology 
could be elucidated. An electrocardiogram and chest x-ray were within normal 
limits. He complained of continuing anorexia and lethargy, and he had lost 14 
pounds since exposure in spite of an adequate food intake. Eight weeks after 
exposure all lost weight had been regained. The only complaint at this time 
was easy fatiguability on exertion. 

Case 3. A 34-year old assistant fire chief was exposed to liquid and 
vaporized chlorobromomethane while perched in the nose wheel housing at- 
tempting to correct a mechanical arrangement. He was unnoticed by his con- 
temporaries and was sprayed in the face with the liquid chemical for 40 seconds 
to a minute. He did not ingest any chlorobromomethane. Total exposure to the 
vapors was three to five minutes. 

Ten minutes after exposure he became dizzy, but he maintained adequate 
orientation. Thirty minutes thereafter he was seized by a severe, throbbing 
pain in both temporal regions, and he complained of a burning sensation in his 
stomach. He vomited twice during the ensuing hour. Physical examination re- 
vealed only injected upper respiratory tract mucosae and conjunctivitis. One 
hour after exposure he was given 100 mg of meperidine hydrochloride intra- 
muscularly, but the headache remained severe. He was referred for overnight 
hospital observation. 

On his admission all routine laboratory tests were within normal limits. 
He was discharged to duty the following day. Three months after exposure the 
patient complained of bitemporal headaches of daily frequency, each lasting 
six or more hours. The onset was typical in each instance with pain beginning 
in one temporal area, becoming bilateral, and being unrelieved by acetylsalicylic 
acid, dextro propoxyphene, or other conventional analgesic agents. Otherwise, 
he was asymptomatic and in good health. 

Comment. The diagnosis of acute chlorobromomethane toxicity will be 
made with difficulty without a history of exposure to the chemical. These pa- 
tients were exposed to unaltered chlorobromomethane vapors and to vapors 
produced by the thermal decomposition of chlorobromomethane with gasoline; 
namely, carbon monoxide, small amounts of phosgene, chlorine, bromine, 

Medical News Letter, Vol. 43, No. 1 31 

hydrogen chloride, hydrogen bromide, soot, smoke, and other unknown break- 
down products. It is not known which of these several compounds contributed 
to the toxic states, but it is probable that the unaltered chlorobromomethane 
vapor was a primary offender. Quantitative analysis of these breakdown prod- 
ucts has not been recorded. 

Table 1. Maximum Allowable Concentration 

Carbon Tetrachloride 25 ppm 

Methyl Bromide 20 ppm 

Chlorobromomethane 400 ppm 

The symptoms and signs of toxicity were referable to the gastrointestinal and 
central nervous systems. It is presumed that the basic offending substances 
were chlorobromomethane and the several bromide -ion-containing decompo- 
sition products. The amount of phosgene produced was considered insignificant. 

This report on acute chlorobromomethane toxicity in human beings is 
thought to be the first so documented in the American medical literature. Toxicity 
followed inhalation of the chemical and its thermal decomposition products. The 
toxic syndrome was characterized by irritative gastrointestinal symptomatology 
and by irritative and narcotic central nervous system manifestations. These 
led to deep coma in two patients, one of whom exhibited uncontrollable con- 
vulsive movements. The second patient became totally apneic and was kept 
alive for two hours with oxygen and artificial respiration. 

The treatment for chlorobromomethane poisoning is supportive. Drug 
therapy failed to alleviate the toxic symptomatology. Respirations must be con- 
trolled by manual restraint to prevent physical injury to the patient. No specific 
antidote for this type of poisoning is known, although dimercaprol has been 
shown to protect laboratory animals subsequently exposed to toxic halide com- 

Chronic pathophysiologic derangements following chlorobromomethane 
exposure in man are not known. In view of the cited animal exposure studies, 
it is suggested that patients be followed closely on an outpatient basis to detect 
possible, subsequent hepatic and/or renal damage. 

Up $ s|e ^t * sjs 

Explosion Hazard of Combustible 
Gases, Vapors and Dusts 

By W. L. Ball PhD, Occupational Health Division Department of National 
Health and Welfare, Ottawa. Occupational Health Bulletin 18(1 0):October 1963. 

Explosion is the forceful expansion of gas. When this expansion occurs so rapidly 
that its pressure is dissipated by the rupture of containing vessels or buildings, 
serious property damage or injury to personnel may result. 

32 Medical News Letter, Vol. 43, No. 1 

Although this article is essentially a discussion of explosion from the 
combustion of air-borne material, it provides an opportunity to examine briefly 
the causes and prevention of explosions that result when gas pressure builds 
up by other means. 

An expanding liquid exerts pressure over a short distance only and this 
force is so quickly dissipated that there is little hazard from a rush of liquid 
or the flying pieces of the containing vessel unless the liquid is hot or corro- 
sive. Released gases, however, expand infinitely and the force of their ex- 
pansion may cause damage and injury over a large area. There are three main 
sources of gas explosions: (1) Gas compressed by mechanical means, such as 
a pump, until some part of the containing vessel fails to withstand the pressure. 
(Z) Stored gases or chemicals externally heated to the point where they rupture 
their containers. (3) Combustions of mixture of gases, vapors or dusts that 
build up high pressure. 

Although combustion explosions differ from the first two because fire 
is more likely to follow, they are more complex and harder to avoid. Explo- 
sives and atomic fission will not be considered in this article. Their effect 
also is to cause the rapid expansion of gas. 

The requirements for a combustion explosion are: (1) enough oxygen 
to support combustion; (2) a flammable substance; (3) a source of ignition. Even 
when these three requirements are present an explosion will not occur unless 
the flammable substance is at certain critical conditions. 

Critical Conditions of Flammable Substances. Ignition temperature. 
Before an air-borne mixture ean propagate a flame a portion of it must be 
heated to the ignition temperature — the minimum temperature at which rapid 
combustion becomes independent of external sources of heat. Because there 
is a lag (1 sec for hydrogen and about 100 sec for ethane) this temperature 
must be sustained. Factors that affect ignition temperature are: Percent of 
combustible material and oxygen in the mixture, size and shape of the con- 
tainer, pressure of the mixture. Ignition temperature is thus not a true physical 

Flash point. Flash point is the minimum temperature at which a liquid 
gives off sufficient vapor to form a flammable mixture and is a rough measure 
of its combustibility. Above the flash point combustion will occur if the ignition 
temperature is sustained long enough and the concentration is within flammable 

Flammable and explosion limits. The minimum concentration in air of 
a combustible that will burn are its flammable or explosion limits. Below the 
minimum there is insufficient combustible and above the maximum insufficient 
oxygen. Because the concentration of a volatile substance over its solid or 
liquid form, in a confined space, depends on its temperature, it may be seen 
that there is also a temperature range of flammability. 

Te mperature Range of Flammability . When the vapor and liquid or solid 
states of a substance are at equilibrium there is a minimum temperature below 
which insufficient air-borne material exists to burn and a maximum above which 
there is insufficient oxygen to support combustion. The temperature range of 

Medical News Letter, Vol. 43, No. 1 33 

flammability lies between these limits. The limits of flammability are affected 
to some extent by the direction of flame propagation, the shape, diameter and 
length of confining space, the temperature and pressure of the mixture, the 
percent of water vapor present and, indirectly, the source of ignition. 

Some of the steps that should be taken to control the hazards of gas 
explosion are as follows: (1) Reduce the oxygen content of the mixture by ab- 
sorption, catalytic combination, or the introduction of inert diluting gases or 
vapors such as carbon dioxide, nitrogen or the freons. (2) Operate outside the 
limits of flammability of the combustible material. For example, a liquid may 
be stored or used at a temperature below its minimum temperature of flamma- 
bility. (3) Substitute less flammable materials. The use of helium instead of 
hydrogen in lighter -than -air craft is one of the oldest examples. (4) Eliminate 
ignition sources. The gasoline tanks of millions of automobiles contain flamma- 
ble mixtures but explosions are rare because care is taken to keep ignition 
sources such as lighted cigarettes away from open tanks, (5) Segregate hazard- 
ous operations. Gas tanks, for example, are placed in fields some distance 
from buildings. (6) Provide adequate ventilation. Ideally, operations that evolve 
combustible or poisonous gases, vapors, or dusts should be carried out inthe 
open. In practice, ventilation should be designed to reduce the concentration 
of combustible materials to non-explosive levels. (7) Use release diaphragms 
or vents. Many operations that normally run at comparatively low pressures 
may suddenly produce explosive pressures that will damage equipment and 
injure personnel if a release is not provided. (8) Follow the gas concentration 
with a combustible gas indicator. This should be routine in any operation where 
escaping combustibles may reach explosive conditions. 

A few ounces of flammable liquid can support a dangerous fire, or if 
volatilized, cause an explosion. Such liquids should be: (1) Stored in rooms 
of non-combustible construction. (2) Descriptively labelled. (3) Guarded from 
sources of ignition. (4) Kept in tightly closed containers. 

Tables of ignition temperature, flash points, limits of flammability, 
minimum explosion concentration, etc. are available for gases, vapors, and 
dusts, but their interpretation and application are complex.. In fact, the de- 
termination of concentrations, their comparison with safe levels and the engi- 
neering steps that must be taken to make them meet acceptable limits should 
be left to experts in the field. Familiarity with the conditions that lead to ex- 
plosions and the application of a few common-sense rules may, however, pre- 
vent a disaster. 

While the foregoing recommendations apply particularly to gas and vapor 
explosions, dust explosions are similar in many ways. There are, however, 
differences in the physical properties of dusts that affect their explosion hazard. 
Because they are not as readily dispersed as gases and vapors, the likelihood 
of dusts forming explosive suspensions depends on the size and weight of their 
particles and the turbulence of the air. In a quiet atmosphere even the fine 
dust particles will eventually settle. 

Sources of Ignition. Some sources of ignition follow: static discharges, 
electric sparks from motors, fuses, switches, etc. , frictional sparks from 

34 Medical News Letter, Vol. 43, No. 1 

grinding wheels, hammers, etc. , glowing particles from furnaces and fires, 
open flames, torches, matches and smoking. 

Examples of gas explosions range from those caused by the ignition of 
the hydrogen generated in charging storage batteries to those which demolish 
a building. An explosion can travel through a gas transmission line faster then 
the splitting of the pipe can release the pressure. In December 1957 in the 
Township of Tustin, Ontario, a leak occurred in the 30 inch diameter high pres- 
sure line and explosion destroyed 3. 37 miles of pipeline. Approximately 60% 
of gas explosions and 70% of fatalities are caused by leaks in distribution and 
service piping outside of damaged buildings. 

In the laboratory a source of explosion is the refrigerator. Chemicals 
that are volatile at room temperature are often stored in a refrigerator. The 
main cause of these explosions, as determined by the Federal Department of 
Public Works, is the ignition of the flammable vapors by one or more of the 
eleven arcing points found in the average domestic refrigerator. Another cause 
is the pressure build up that follows power failure. Such explosions are very 
destructive of property and hazardous to personnel. Routine inspection of the 
contents and mechanism of the refrigerator is a good precaution but it also is 
wise to equip the refrigerator door with a magnetic lock that will release before 
the pressure builds up. 

sk jk s&c ste ste jSt 

S urvey of the Most-Frequently 
Accidentally Ingested Products 

National Clearinghouse for Poison Control Centers, USDHEW PHS, 
Washington D. C. , pgs 1-4, September-October 1963. 

A primary function of the National Clearinghouse for Poison Control Centers 
is analysis of the data reported by the centers. Currently, about half of the 
511 centers throughout the country are using a standard report form (PHS- 
2805). In 1961 there were 42,000 cases submitted for statistical processing. 
Approximately 90 percent were reports of ingestions among children under 5 
years of age. Summaries of the tabulations were distributed to the participating 
centers. Consolidated summaries were sent to the State Health Departments 
concerned and Public Health Service Regional Offices. 

After coding and tabulation, the individual case histories are filed by 
category (such as laxatives, bleaches, tranquilizers, etc. ) and then subdivided 
by trade name. This file serves to provide clinical information both on cate- 
gories of products and on individual trade name items that make up each cate- 

An analysis of the accidental ingestions among children under 5 years 
of age shows that 10 categories out of 80 currently used accounted for approxi- 
mately half the cases. The following table lists the relative frequencies of such 
ingestions during 1961. 





















Medical News Letter, Vol. 43, No. 1 35 

Types of Substances Percent of Total 

1 . Aspirin 

2. Insecticides (exc. mothballs) 

3. Bleach 

4. Detergents, soaps, cleaners 

5. Furniture polish 

6. Kerosene 

7. Vitamins and iron preparations 

8. Disinfectants, deodorizers 

9. Lye, corrosives 
10. Laxatives 

If suicides and accidental ingestions in persons 5 years and over were also 
considered, sedatives -barbiturates (4. 5% of all ingestions) and tranquilizers 
{2. 8% of all ingestions) would be included in the "top 10. " However, since 
poison control centers are concerned primarily with accidental poisoning, the 
following observations will be confined to those categories of substances most 
frequently ingested by small children. 

Individual case reports are on file for those ingestions reported to the 
Center since July 1959, a 30 month study period in which approximately 90, 000 
reports were analyzed. Within each of the "top 10" categories, the number of 
different products and the frequency of each were tabulated. Information con- 
cerning hospitalization was tabulated on the 10 most frequently ingested prod- 
ucts within each of the "top 10. " This report, then, would cover 100 individual 
products except that the kerosene category is not broken down by trade names. 

On further review of the cases accumulated in this 30 month period, it 
was found that 34, 651 reports identified the name of the ingested product in 
these "top 10" categories. Of 1722 different trade name products represented, 
15 were reported 200 or more times, and 16 others were reported 100 or more 

It was found that 15 products (acetyl salicylic acid, kerosene, and 
ammonia each counted as a single product) accounted for 0.9 percent of the 
individually identified products, but for 69. 1 percent (23,940) of the cases. 
When the 31 products named 100 or more times were analyzed, 1. 8 percent 
of the individually identified products accounted for 76. 3 percent (26,425) of 
the ingestion cases. The remaining 1, 691 products represented 98. 2 percent 
of the identified substances but only 23. 7 percent of the cases. Aspirin, of 
course, led the 10 most frequently ingested products with almost half of the 
cases, followed by "Clorox" (5. 4%), kerosene (4. 8%), "Ex-Lax" (2. 9%), and 
"Drano" (2.9%). 

Children hospitalized from these ingestions ranged from 6. percent 
to as high as 55 percent, with the figures based on the number of cases for 
which data concerning hospitalization were available. The criteria for hospital- 
izing an ingestion case vary from hospital to hospital. Many of the cases were 

36 Medical News Letter, Vol. 43, No. 1 

admitted either because of a hospital policy or for 24 hour observation. The 
average hospitalization for the 15 products was 20. 6%, and 20% for the combined 
products in all of the selected groups of substances. 

Products A mong "Top 10" Substances Which 
Were Reported 100 or More Times 
July 1959-December 196l ~ 


1. Aspirin 

2. "Clorox" 

3. Kerosene 

4. "Ex-Lax" 

5. "Drano" 

6. Ammonia 

7. "Pride" Furniture Polish 

8. "Lysol" 

9. "Old English" Polishes 

10. "Gator Roach Hives" 

11. "Lestoil" 

12. Lye 

13. "Purex" 

14. "Pine -Sol" Disinfectant 

15. "Black Flag" 

16. "Real-Kill" 

17. "Raid" 

18. "Windex" 

19. "Comet" 

20. "Harris Famous" Roach Tablets 

21. "6-12" Insect Repellent 

22. "Poly-Vi-Sol" 

23. "Mr. Clean" 

24. "Sani-Flush" 

25. "Carter's Little Pills" 

26. "Roman" Cleaner Bleach 

27. "Joy" 

28. "Chocks" Vitamins 

29. "Ajax" 

30. "Lilly's" Ant Cup 

31. "Easy-Off" Oven Cleaner 

Total 31 26, 425 20. 1 

Total Cases 34,651 20.0 

with trade names specified 
* Based on cases with known information regarding hospitalization. 


% Hosp. * 

15, 546 





39. 3 














21. 3 




55. 1 




31. 5 


25. 5 


26. 3 


33. 7 


3. 1 






8. 5 






22. 5 






5. 7 






27. 3 



Medical News Letter, Vol. 43, No. 1 37 

In analyzing ingestions among children under 5 years of age, the identi- 
fication of the trade-name products most-frequently encountered was included 
for a number of reasons. When relatively few products account for the majority 
of ingestions, the necessity is clear for having the information on the ingredi- 
ents, symptoms, and treatment for these cases instantly available. Because 
information is generally available on the more common products (whether by 
reason of volume of sales or popularity of the product), the less frequently 
mentioned products probably cause the poison control center the most diffi- 
culty. In the latter case, the formulations are less likely to be readily avail- 
able, causing delay in the disposition of the child. In. brief, the 15 products 
that are mentioned ZOO times or more should be familiar to the doctors in the 
poison control centers, whereas the 5, 000 to 6,000 products that have been 
ingested a fewer number of times will present greater problems. 

On several occasions in these tabulations, the trade name mentioned 
on the report fails to specify the individual product of a company. Thus, several 
similar products with company trade name may be grouped together ; examples 
of this are "Black Flag, " "Real-Kill, " "Raid, '» and "Old English" Furniture 
Polish. Other tables include merely a chemical identification, since this was 
the principal method of identifying the products when these cases were re- 
ported. Therefore, in one table both potash and lye are mentioned individually, 
although several of the products in the table might have contained either or 
both of these substances. Similarly, ferrous sulfate and ammonia are listed 
in their appropriate categegories. The tables, therefore, reflect the named 
products that were identified by the individual poison control centers and, al- 
though some of the lists might not be mutually exclusive, there are still many 
interesting and informative conclusions that might be made. 


The Division of Occupational Health of the U. S. Public Health Service announced 
the release of "Preventing Dermatitis, If You Work With Epoxy Resins, " PHS 
Publication No. 1040. 

Since epoxy resins were introduced to American industry a few years 
ago, they have gained widespread usage. However, epoxy resins may cause 
troubling and disabling dermatitis, or skin disease, of employees who do not 
observe certain safeguards in working with the resins. 

The new publication describes for the worker and his supervisor the 
hazards inherent in working with epoxy resins. Precautions for handling the 
materials, plant housekeeping procedures, and personal hygiene rules are 
outlined briefly and illustrated by simple line drawings. A listing of sources 
of additional information on the resins completes the leaflet. 

Single copies of the publication are available from the Division of Occu- 
pational Health. Copies may be purchased from the Superintendent of Documents, 
U.S. Government Printing Office, Washington D. C. (10 cents each; a discount 
of 25 percent for orders of 100 or more). 

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Medical News Letter, Vol. 43, No. 1 



Naval Reserve Promotion Zones 
and Tentative Convening Dates 

Listed below are the 1961 Register Numbers of the junior officer in each re- 
spective promotion zone. 









Promotion to Rear Admiral 


Promotion to Captain 


No board authorized 
No board authorized 
No board authorized 

No board authorized 
No board authorized 

Promotion to Commander 

















• 50 


















Promotion to 

Lieutenant Com: 




















XXX 7 


Promotion to the grade of lieutenant (male) will include all lieutenants (junior 
grade) with date of rank of 4 May 1962 and senior. 

Promotion to the grade of lieutenant (Wave) will include all lieutenants (junior 
grade) with date of rank of 31 December 1961 and senior. 

Medical News Letter, Vol. 43, No. 1 39 

The Naval Reserve selection boards are scheduled to convene as follows: 

Rear Admiral (Line and Staff) 7 Jan 1964 

Captain (Line) 14 Jan 1964 

Captain (Staff) 3 Mar 1964 

Commander (Line) 21 Jan 1964 

Commander (Staff) 3 Mar 1964 

Lieutenant Commander (Line) 10 Mar 1964 

Lieutenant Commander (Staff) 28 Apr 1964 

Lieutenant (Line) 7 Apr 1964 

Lieutenant (Staff) 28 Apr 1964 

Warrant Officers 23 Mar 1964 

j|< if if if. if if 

Navy Ensign 1915 Medical Program 

Naval Internships (continued) 

5. Salary. A medical school graduate accepted as an intern will be commis- 
sioned as lieutenant (junior grade), Medical Corps, United States Naval 
Reserve, and will receive the compensation and privileges of his rank. 
Interns with dependents receive approximately $ 10,715 per year while 
those without dependents receive approximately $10,414 per year. Currently, 
promotion to the rank of lieutenant usually occurs early in the internship 
training period. After such promotion, the amount received per year is 

the same as for a lieutenant (junior grade), 

6. In order to become eligible for consideration for a naval internship, you 
must first register with the National Intern Matching Program. Application 
for the naval internship may then be secured by visiting or writing the 
nearest U. S. Navy Recruiting Station or the nearest naval hospital in the 
continental United States. In filling out an application form, we suggest you 
list five hospitals in order of preference. In most instances we have been 
able to make an assignment from among the first three listed. 

7. Applications for intern training are accepted between 1 September and 1 
December of each year. That portion of the application pertaining to intern- 
ship is accepted between 1 October and 1 December in accordance with the 
provisions of the National Intern Matching Program. 

8. In order to permit processing of your application in sufficient time to meet 
all deadline dates , it is suggested that you submit your application as early 
as possible after 1 September. Your attention is invited to the fact that naval 


Medical News Letter, Vol. 43, No. 1 

internships carry no obligated service requirement. Interns, if they so 
desire, may be released to inactive duty at the conclusion of their intern- 
ship provided they have no obligation to serve on active duty under the 
Universal Military Training and Service Act, as amended, or under the 
Senior Medical Student Program. 

Any additional information may be obtained upon request from the Bureau 
of Medicine and Surgery, Department of the Navy, Washington 25, D. C. 

(To be continued) 

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